Commentary: Age-based vaccine distribution is not only unethical. It’s also bad health policy


Americans are queuing up for coronavirus vaccinations, but some states have started pushing vulnerable residents out of the vaccine line. Maine removed eligibility for all front-line workers and people with high-risk medical conditions, instead basing vaccine access solely on age. (It later restored eligibility for teachers, following the Biden administration’s announcement that it would prioritize them.) Other states, such as Connecticut and Nebraska, have made similar age-focused changes. In Maine and Connecticut, a healthy 50-year-old working from home will be eligible for vaccination, while a 44-year-old front-line worker with diabetes living in a hard-hit community will be turned away.

This makes no sense. Age-only distribution is unethical, likely illegal and bad health policy. It also abdicates the government’s responsibility to seek equity and proactively reach out to high-risk people in search of the mirage of value neutrality. Simplicity and speed are valuable, but equity and fairness should not be abandoned in the pursuit.

Some claim that basing vaccine allocation on age alone will save the most lives. This is not true. Age-adjusted covid-19 mortality risk for some disabilities, such as Down syndrome, is up to 10 times higher than for the general population. For Pacific Islander, Black, Latino and Native Americans, it is up to two and a half times higher compared with White Americans. Native Americans age 40 to 49 suffered death rates twice those of White Americans a decade older. Even before equity is considered, incorporating sources of risk in addition to age will save more lives than ignoring them.

Age-only policies also entrench disparities. The median age for White Americans is 44; for minority Americans, it is 31. Yet poorer and minority Americans have died more often and earlier in life from covid-19. They are likelier to be front-line workers and to have high-risk medical conditions.

Purely age-based prioritization is also inconsistent with American values. In public opinion surveys, respondents decisively support prioritizing people of all ages with high-risk medical conditions and minority communities hit hard by covid-19. Respondents do not care only about saving the most lives; they emphasize other considerations, such as preventing long-term complications and protecting front-line workers. The public also strongly supports prioritizing teachers and grocery-store workers, even over healthy adults older than 65.

Federal law enforces these values. When allocating scarce medical resources, a state is “only permitted to consider age as one factor as part of its overall decision-making.” State departments of health may not practice “blanket exclusion of individuals based solely on age,” as they learned when resolving challenges to ventilator allocation policies. To be legal, age-only policies must be explicitly adopted by an “elected, general purpose legislative body,” not by regulatory fiat.

New evidence further weakens the case for age-only policies. Vaccines likely reduce transmission of the coronavirus, so vaccinating people in high-transmission settings, such as crowded or communal living situations, also protects others. Some studies suggest that viral mutations are more likely when unprotected people who are immunocompromised become infected, which supports vaccinating, for example, organ-transplant recipients before healthy 50-year-olds.

Some states complain that considering factors beyond age slows down vaccine distribution. But excluding everybody below a certain age from eligibility does nothing to get vaccines into arms faster. In fact, hard age cutoffs can cause delays. Couples who are 52 and 48 can’t be vaccinated together, and mobile and employer-based vaccination sites have to dole out doses in dribs and drabs. Some of the fastest-moving states, such as Alaska, are aiming for speed by using geography rather than age.

Instead of relying only on passive, first-come first-served websites, states should proactively reach out to high-risk people, avoiding time-consuming verification at vaccination sites. States could also empower health professionals to use information from medical records or the Centers for Disease Control and Prevention’s Social Vulnerability Index, which identifies communities that need support preparing for or recovering from health threats. It is irresponsible for states to ask for funding to strengthen their public health systems while refusing to plan for active outreach to people facing overlapping risks.

Others obsess over fears of fraud. Age-based policies are hardly immune from misrepresentation. Already, some people have disguised themselves as “grannies” to skip ahead in the vaccine line. No priority system can perfectly deter fraud. But we should not deny vulnerable people vaccines they need merely because a few fraudsters might get vaccines early.

States have already offered vaccines to many of the most vulnerable Americans by prioritizing nursing-home residents regardless of age. They also have offered vaccines to other Americans older than 65, who are at higher risk of death. When choosing between 45- and 55-year-olds we should give less weight to age and more weight to other risk factors, including where people live and work. In doing so, we can use vaccines to address injustice and save more lives.

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Govind Persad is a law professor at the University of Denver Sturm College of Law. Emily A. Largent and Ezekiel J. Emanuel are medical ethics and health policy professors at the University of Pennsylvania Perelman School of Medicine.



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